From the Division of Plastic Surgery, Hospital das Clínicas, Faculty of Medicine, University of São Paulo.
SURGICAL TREATMENT OF ENDOCRINE
EXOPHTHALMOS BY REMOVAL OF ORBITAL FAT:
CLINICAL EXPERIENCE
Marcus Castro Ferreira, Paulo Tuma Jr., Márcio Paulino Costa, Walter Bloise and Carlos Alberto Rodrigues Alves
RHCFAP/3096 FERREIRA MC et al. - Surgical treatment of endocrine exophthalmos by removal of orbital fat: clinical experience. Rev.
Hosp. Clín. Fac. Med. S. Paulo 57(5):217-222, 2002.
PURPOSE: To report a series of 73 patients with endocrine exophthalmos treated by removal of orbital fat using the transpalpebral approach during the period 1989 to 1999.
METHODS: The operation was performed according to the technique described by Olivari. Aesthetic analysis was done preoperatively and postoperatively (more than 6 months after surgery). The number of complications was also observed.
RESULTS: The average volume of resected fat was approximately 7.6 mL per orbit. No major complication was observed. In 9 patients with epiphora, all improved. One patient developed postoperative diplopia and 5 complained of temporary diplopia. Appearance improved in 62 patients (85%).
CONCLUSION: Surgical removal of orbital fat associated with endocrine exophthalmos provides consistent improvement in appearance with a low rate of complications. Additional procedures may be indicated to improve the cosmetic outcome.
DESCRIPTORS: Endocrine exophthalmos. Transpalpebral surgery. Orbital fat.
INTRODUCTION
Endocrine exophthalmos is a syn-drome that appears in some patients with thyroid disease. Although there are many signs included in the syn-drome, only bilateral proptosis and eyelid retraction are pathognomonic. The “lid lag” with stare when looking downwards is typical, but it can appear in other diseases. Graves’ diseases is the most common cause of exophthal-mos1-4.
Indication for surgery has been tra-ditionally determined considering pro-gressive loss of visual acuity, degree of systemic thyroid disease, and im-pairment of extraocular muscle func-tion, either fibrotic or inflammatory. Moderate or severe ocular impairment
in thyroid disease is uncommon; less than 5% of patients require surgical treatment. More recently, aesthetic concern has become a main motivation for surgical treatment.
Classical surgical techniques are comprised of the many forms of orbital decompression, done through oste-otomy of the orbital walls. Orbital de-compression has been the preferred method for surgical correction of se-vere forms of disease5-7.
Some authors have included aes-thetic concern among the indications for orbital decompression8,9. A number
of postoperative complications were reported in association with this rather extensive procedure, including paresthesia in the area of infraorbital branch innervation5,7, diplopia because
of a misalignment of extraocular mus-cles, oculomotor disorders varying from 30% to 70% of strabismus in some series7, globe ptosis, and less
fre-quently, lesion of the nasolacrimal duct, liquor fistula, and sinusitis2.
thus had no need of bone surgery10-12.
Despite the clear advantages of this approach, the technique has not gained widespread acceptance in clini-cal practice in our country and remains almost unknown in most centers.
We started using this technique of orbital fat removal in 1989 in the Hos-pital das Clinicas, and the initial cases were published in 19924.
We report now a larger series, treated during the last 10 years, to more extensively discuss the tech-nique, the results, and the complica-tions.
METHODS
From 1989 to 1999, 73 patients with bilateral exophthalmos associated with Graves’ disease were surgically treated. Sixty-one were female and 12 male, with ages ranging between 24 and 52 years.
The patients were always referred for surgical treatment after being con-sidered stable for more than 1 year af-ter treatment of thyroid disease.
Eighty percent of the patients had grade III exophthalmos (proptosis of 3 mm or more, with or without eyelid swelling), and 20% had grade IV (in-volvement of extraocular muscles, usu-ally with diplopia, limitation of move-ment in extreme positions, and evident restriction of movement. There was no severe impairment of vision in any case. All patients complained of aes-thetic disturbance with associated psy-chological problems involving an infe-riority complex. The dissatisfaction with their facial appearance was impor-tant and related to difficulties in their professional and personal relationships.
SURGICAL PROCEDURE
The operation was performed under general anesthesia in all cases. The
up-per eyelid was opened through a con-ventional blepharoplasty incision. The orbicular muscle was divulsed, and the orbital septum split to expose the su-perficial orbital fat pouches (lateral and medial), which were resected as deeply as possible, with care to avoid injuring the lacrimal nerve laterally, and in the medial area, the supraorbital nerve. Hemostasis was done only with a bipolar coagulator, and magnifying loupes were used.
The lower lid was then incised about 1 mm from the lid margin. After divulsing the eyelid orbicular muscle, the orbital septum was reached and then incised. Fat was removed from lat-eral to medial pouches until the infe-rior oblique muscle was exposed. At this point, the fat pouches were di-vided into 2 parts to avoid injuring the muscle and its innervation.
Aspiration drains were used for 48 hours. The procedure was performed on only 1 orbit at a time, with the other being carried out after at least 45 days. The volumes of fat resected from the upper and lower lids were verified, and the total volume was computed. No skin was removed from the eyelid in any case.
In 46 patients who had significant a degree of retraction of the lower lid, a cartilage graft was used, which was removed from the auricular concha and fixed on the tarsus with 2 or 3 stitches of 5-0 nylon.
In 15 patients with retraction of the upper lid, the aponeurosis of the mus-cle levator palpebrae was incised par-tially to elongate the muscle.
The aesthetic result was accessed by both surgeon and patient during the preoperative and postoperative periods (more than 6 months after surgery). Aesthetics were graded as much im-proved, imim-proved, not imim-proved, or worsened.
The number of complications re-lated to the procedure was also docu-mented.
RESULTS
The average volume of resected fat was approximately 7.6 mL per orbit, with a maximum of 11.5 mL and a minimum of 2.0 mL.
No severe postoperative complica-tion was observed, such as loss of vi-sion, retrobulbar hematoma, infection, paresthesia on the infraorbital nerve territory, damage to the lacrimal duct, liquor fistula, sinusitis, or ptosis of the eyeball.
Preexisting epiphora in 9 patients improved after the operation. Seven patients developed postoperative di-plopia for up to 3 months; 1 patient developed more durable diplopia. In 2 patients who already had diplopia, no worsening was observed.
Regarding the aesthetic result, 29 patients said that their appearance was much improved after the operation, and the same opinion was expressed by the surgeon; 23 were considered improved, and for 11 there was no ma-jor aesthetic gain, although there was no worsening either. The aesthetic as-pect of the cartilage grafts, which were somewhat visible, and residual upper lid shortening were the most common reasons for dissatisfaction; fullness of eyelids was not a factor producing dis-satisfaction.
DISCUSSION
Patients with hyperthyroidism may develop endocrine ophthalmopathy in 40% of the cases, and the condition is frequently resistant to conservative therapy, which provides no more than small regression12.
The use of steroids can be helpful in the acute phase of the process2,3,
In the stable exophthalmos, appear-ance is the most important concern for the patient, and surgical treatment should be considered. Procedures de-scribed for severe cases, such as the or-bital decompression using osteotomies of the orbital walls, either on the infe-rior and medial walls13,14, have no
indi-cation for these cases because of the rate of reported complications2,5,6,7,12,13. For
that reason, osteotomy of the orbital wall is rarely used in Brazil, except in severe cases when there is risk of vision loss (malignant exophthalmos).
In the majority of the cases with aesthetic dissatisfaction, the patient preferred not to undergo radical orbital osteotomies and asked for a less ag-gressive approach. After the experience of Olivari10, we in Brasil started in
1989 to use the technique of trans-palpebral removal of orbital fat4.
In this last decade, we have learned, with this clinical experience of 73 pa-tients, that although the operation for resection of orbital fat is more extensive when compared with the aesthetic Figure 1 - a) and b) Preoperative – aspect of exophthalmos
Figure 2 - a) and b) Postoperative – result after 2 years. Removal of fat plus cartilage graft
Figure 3 - Preoperative aspect
Figure 4 - Postoperative – after 2 years
and progressive exophthalmos, and even then, it was reported to be par-tially successful only if performed within the first 6 months after the
blepharoplasty, it is still a relatively non-invasive procedure and is not fol-lowed as we initially feared by compli-cations, such as retrobulbar hematoma, infection, fistula, or blindness. Our re-sults are similar to those reported lately by Olivari and others11,12,15,16. No
infraorbital nerve parestesia was ob-served, a finding that is rather common after orbital decompression through os-teotomy5,7,13,17. However, there is a
learn-ing curve, and this procedure should only be performed by an experienced surgeon with additional training in microsurgery.
Only 1 patient developed diplopia that did not improve after the opera-tion. This can be associated with ana-tomical changes in the extraocular muscles, which were thick and fibrous and become stretched after the proce-dure due to the content-container re-lationship, which prevented its new accommodation. Five patients had postoperative temporary diplopia that improved with time; this rate of occur-rence is consistent rates reported in the literature12. Temporary diplopia may be
related to the fact that the operation was performed in one orbit at a time, but data is not conclusive at this point. With more confidence on the technique, we are planning to operate on both orbits at the same time in se-lected cases.
Epiphora improved because the cornea was less exposed postopera-tively. In some cases, the cartilage graft was important for correcting the lid re-traction and the ectropion. In our ini-tial cases, cartilage grafting was per-formed as another procedure after some months when the lid retraction was al-ready defined; but lately, we have per-formed cartilage grafting in the same operation.
Strabismus, when present preope-ratively, was not changed after surgery. It has never occurred as a complica-tion, an important consideracomplica-tion, since
we know that the rate of this compli-cation after osteotomy was reported to be as high as 70%2,6,18.
Aesthetics, as pointed out, was the main motivation for patients who asked for the operation. Evaluation of results after any aesthetic procedure is not an easy task, since there is still no widely accepted method to assess aes-thetics. It is been said that the outcome would be similar to the evaluation of an object of art. A subjective aesthetic judgment of the patient or the surgeon is required, which is insufficiently controlled to reach the status of “sci-entific” criteria.
Patients with endocrine exophthal-mos present many variables that con-cur to comprise the “unaesthetic” ap-pearance—namely, eye enlargement and proptosis and the association with other conditions, such as eyelid retrac-tion, ptosis, scleral show, strabismus, or ectropium.
It was impossible to accurately as-sess the aesthetic improvement achieved by the removal of fat; there-fore, we considered the degree of sat-isfaction of patients after all the surgi-cal stages. The surgeon was also surgi-called on to give his opinion.
Accordingly, although the amount of removed fat was significant in each case (an average of 7.6 mL per orbit), there is important personal variation among the patients; consequently, treatment should be customized for each patient.
Probably the most important factor for the aesthetic prognosis after the operation is the relationship between the volume of enlarged fat deposits and that of the extraocular muscles. Both are known to be increased in ex-ophthalmos12, but in some patients, the
fat component is more significant, whereas in others the volume of the muscle is mainly responsible for the protrusion.
Removal of fat is more properly
in-dicated in the cases in which the fat volume prevails; this can be detected by tomography and by magnetic reso-nance, but it is still not always possi-ble, and assessment is not done rou-tinely. In our study, even in the mus-cle enlargement group, the reduction of stasis resulting from the removal of fat from the orbit helped produce a re-gression of edema in the extraocular muscles, and thus secondarily pro-duced a reduction in the protrusion.
Other complementary procedures can be used; however, an extensive list of procedures is a discussion beyond the scope of this paper. Even Olivari12
has not discussed extensively all the aesthetic features related to this syn-drome. Most patients had some com-plementary operations done, the results after cartilage grafts being the most impressive.
Cartilage grafts from concha as a spacer for the lower lid can be per-formed at the same time or subsequent to the orbital decompression and were not part of the original technique de-scribed by Olivari10, but are frequently
used nowadays for several other plas-tic surgery indications.
The results obtained with this type of procedure should not be compared with orbital decompression methods through osteotomy, because the indi-cations are not the same. In our view, bony orbital decompression should not be performed if the indication is mostly aesthetic.
RESUMO RHCFAP/3096
FERREIRA MC e col. - Tratamento cirúrgico do exoftalmo endócrino por remoção da gordura orbitária: experiência clínica. Rev. Hosp.
Clín. Fac. Med. S. Paulo 57(5):
217-222, 2002.
OBJETIVO: Apresentamos uma
série de 73 pacientes com exoftalmo endócrino tratados pela Divisão de Ci-rurgia Plástica do Hospital das Clíni-cas da Faculdade de Medicina da Uni-versidade de São Paulo, através da re-moção da gordura orbitária usando acesso transpalpebral, durante o
perío-relevante para avaliação de exoftalmo.
CONCLUSÃO: Esta abordagem,
ainda não usada rotineiramente no Brasil, constitui uma nova via de aces-so para o tratamento do exoftalmo endócrino. Os resultados foram consis-tentes, com baixo índice de complica-ções. Outros procedimentos devem sempre ser realizados, visando à melho-ra dos resultados estéticos.
DESCRITORES: Exoftalmo
endócrino. Cirurgia transpalpebral. Gordura orbitária.
do de 1989 a 1999.
MÉTODOS: A avaliação foi
reali-zada através de análise estética, no pré e no pós-operatório (maior do que seis meses). O número de complicações também foi mensurado. Nove pacien-tes apresentaram epífora, todos com melhora espontânea. Um paciente de-senvolveu diplopia no pós-operatório, e cinco apresentaram diplopia tempo-rária. A aparência melhorou em 62 pa-cientes (85%). Uma retroposição mé-dia de 2,74 mm foi observada, apesar de o método não ser mais considerado
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